Posted on 07/15/2017 in Integrative Understanding of Infertility

Male Infertility: Causes, Testing, Treatment

Male Infertility: Causes, Testing, Treatment

INTRODUCTION

At present, the issues of researching the essence of male’s infertility: its causes, testing and treatment have become an interdisciplinary research mainstream focus for both paradigms of modern andrology and male reproductive endocrinology. Male infertility has determined scientists’ very close attention to the key issues “male infertility and its causes;” “male infertility and testing” “male infertility and treatment”, which can be vividly illustrated by the fact that recently there have been more than 45000 analytical overviews concerning this question published (just according to PubMed data) let alone numerous scientific publications and research papers all over the world. Together with this, despite the problem of male infertility has been inclusively described and analyzed comprehensively in modern reproductive sciences, we have chosen the major causes and revealed the basic information about them.

To understand the challenges associated with fertilization process, we should focus on the male’s part in fertilization, which is quite wonderful and amazing. About 200 million sperm are mixed with semen to form ejaculate. In most men, 15 to 45 million of these sperm are healthy enough to fertilize an egg, although only 400 survive after a man ejaculates. Only 40 of those 400 reach the vicinity of the egg. After another process called capacitation (an explosion that allows the remaining sperm to drill a hole through the tough outer layer of the egg), only one lone sperm reaches the egg for fertilization and conception.

Should a couple have trouble conceiving, despite trying for more than a year, both partners may be checked for issues leading to infertility. In 25% – 30% of infertile couples, the problem is solely with the male partner. Infertility in a man may be the only reason that a couple can’t conceive, or it may simply add to the difficulties caused by infertility in his partner.

Male infertility, its causes, testing and treatment, is a really complicated topic. Though the following is general information, which represents basic causes of a male’s infertility, we strongly recommend that you consult a specialist in male reproductive health who can fully evaluate, diagnose and treat your particular situation.

(1)           MALE REPRODUCTIVE CELLS

What are sperm? Sperm are the male reproductive cells. To have a baby, genetic material from the sperm must combine with the genetic material from an egg, in a process called fertilization. Sperm are highly specialized cells and are made up of three parts: a head, neck and tail. In the head is a structure called the nucleus, which contains 23 tightly packed chromosomes (genetic material). The head is designed to bind to and then penetrate (enter) the egg. The neck of the sperm joins the head to the tail. The part of the tail nearest the neck contains the mitochondria, which provides the energy for the sperm to move. The tail moves in a whipping motion to push the sperm towards the egg. Healthy, fully developed sperm are very small (0.05 millimeters long). Spermatogenesis (sperm production) is a continuous process with millions of sperm being made each day. It takes about 70 days to complete the development of sperm that are able to swim and fertilize an egg.

(2)           CAUSES OF MALE INFERTILITY

One of the toughest challenges in describing the male’s infertility is the inclusiveness in representation of its causes. Having observed the numerous scientific articles and analytical overviews concerning this question, we found out the major causes, which can be categorized in the following way:

(1)           Sperm production problems; 

(2)           Blockage of sperm transport;

(3)           Sexual problems; 

(4)           Hormonal problems; 

(5)           Sperm antibodies.

Additionally, as a result of studying the causes of male infertility, we can represent four major causes: (1) Low sperm count; (2) Slow sperm motility (movement); (3) Abnormal morphology (shape and size of sperm); (4) Epididymal obstruction. 

(1)           LOW SPERM COUNT: OLIGOSPERMIA

The most common cause of male infertility is a problem with making sperm in the testes, resulting in a low sperm count (oligospermia). This is the medical term used to describe the condition when the sperm count is low, less than 15 million sperm/ml. Andrologists are usually very careful about not drawing conclusions too quickly, but analyzing accurately their nuanced answers, we can make a conclusion about the essence of low sperm count.

When the Andrologists determine the sperm count, two factors are involved, sample volume and sperm concentration. The total sperm count is the product of the sperm concentration (million/milliliter) multiplied by the sample volume (milliliters). Together, these two values tell us how many total sperm are present in the ejaculate. The World Health Organization (WHO) has determined the normal ranges for sample volume, concentration, and total sperm count.

Volume –– The average volume of an ejaculate is between 1.5–5.0 milliliters (ml). Lower volumes are sometimes associated with blockage and/or retrograde ejaculation (ejaculation that refluxes into the bladder).

Concentration –– The normal sperm concentration is ≥20 million sperm per milliliter of semen. Decreased counts can indicate abnormal or impaired spermatogenesis or blockage while increased counts are often found in cases of prolonged abstinence.

Total Sperm Count –– The World Health Organization has determined the lower reference limit (2.5th percentile) to be 39 million sperm per ejaculate.

Either low numbers of sperm are made and/or the sperm that are made do not work properly. This may also be associated with reduced sperm movement and abnormality shaped sperm. If there are no sperm at all in the semen sample, the condition is medically termed as azoospermia.

NO SPERM: AZOOSPERMIA

Azoospermia is the medical term that’s used when there is virtually no sperm count in the ejaculate. Accurate diagnosis of azoospermia is complicated. Correctible causes must be found and treated. Even then, if there are no sperm in the ejaculate, sperm can often be harvested and used to achieve fertilization. What we’re looking at here is whether the problem lies in the sperm production or in the delivery. Is it the testes that are not producing sperm or are they unable to deliver it in the ejaculate? The initial evaluation is to distinguish between these two conditions. If the testes are making sperm but none are in the ejaculate, the sperm must be retrieved by some other mechanism, either by restoring the normal flow of sperm or by circumventing it. If the testes are not producing sperm, we need to explore whether the problem can be reversed. Even if the problem cannot be reversed, there are a number of cases in which the level of spermatogenesis is advanced enough to allow sperm “harvesting” in conjunction with in–vitro insemination and other advanced reproductive techniques (ART) and micromanipulation. The following information transparently represents and inclusively describes causes for both production and delivery problems.

Production Problems

From the experiential point of view it has been proved, that there are three major causes for lack of sperm production are hormonal problems, testicular failure, and varicocele.

Hormonal Problems

The testicles need pituitary hormones to be stimulated to make sperm. If these are absent or severely decreased, the testes will not maximally produce sperm. Importantly, men who take androgens (steroids) for body building, either by mouth or injection, shut down the production of hormones for sperm production.

Testicular Failure

In general, this means that the sperm-producing part of the testicle (the seminiferous epithelium) isn’t making adequate numbers of mature sperm. This failure may occur at any stage in sperm production for a number of reasons. Either the testicle may completely lack the cells that divide to become sperm (this is termed “sertoli cell–only syndrome”) or there may be an inability of the sperm to complete their development (this is termed a “maturation arrest.”) This situation may be caused by genetic abnormalities. A physician must screen for these.

Varicocele

As we’ve discussed in other sections, a varicocele is a dilated vein in the scrotum (much like varicose veins in the legs). These veins are dilated because the blood does not drain properly from them. These dilated veins allow extra blood to pool in the scrotum, which has a negative effect on sperm production. This condition may be corrected by minor out–patient surgery.

Sperm Delivery Problems

Ductal Absence or Blockage

Generally, a sperm delivery complication is caused by a problem in the ducts that carry the sperm, or problems with ejaculation. The sperm–carrying ducts may be missing or blocked. Both sides of the patient’s vas deferens may be absent from birth. Or he may have obstructions either at the level of the delicate tubular structure draining the testes (the epididymis) or higher up in the more muscular vas deferens. He may have become mechanically blocked during hernia or hydrocele repairs.

Sperm are stored in sacs called the seminal vesicles, and then are deposited in the urethra, which is the tube through which men urinate and ejaculate. The sperm must pass through the ejaculatory ducts to get from the seminal vesicles to the urethra. If these are blocked on both sides, no sperm will come through.

In conclusion, there may be problems with ejaculation. Before a man ejaculates, the sperm must first be deposited in the urethra. This process is called emission. There may be neurological damage from surgery, diabetes, or spinal cord injury that prevents this from happening. Also, for the sperm to be pushed out the tip of the penis, the entry to the bladder must be closed down. If it does not close down, the sperm will be pushed into the bladder and washed out when the patient urinates.

(2)           SLOW SPERM MOTILITY (MOVEMENT)

Low sperm motility (ability to move): sperm motility is the ability of sperm to swim or move forward. A healthy sperm has a lashing tail, which helps it swim through the woman’s reproductive system. Poor motility means it is hard for the sperm to swim towards the egg: the sperm is simply not able to reach the egg because of its poor motility.

Some of the most common causes of low sperm motility include the following:

Excessive stress –– it seems quite unsurprising, that stress has become so integral to our lives. And, at this point, the proportion of conversation dominated by complaint has reached unacceptable heights. It was proved, that stress can have a number of negative health effects, including issues with fertility and it is vital to understand that very extreme stress can disrupt the endocrine system, triggering infertility;

Excessive heat –– excessive heat can result in many problems with the sperm, causing infertility issues. Excessive heat can have a detrimental effect on normal sperm production. It is for this reason that nature has placed the testicles outside the body in the scrotum rather than in the abdomen like the ovaries. Soaking in a bathtub full of hot water can almost halt sperm production completely. Sources of this heat may include constricting undergarments and clothing, saunas, hot tubs, and laptops;

Side effects of medications –– some medications can actually cause problems with sperm motility as a side effect of regular use.

(3)           ABNORMAL MORPHOLOGY (SHAPE AND SIZE OF SPERM): TERATOSPERMIA

A healthy normal sperm is shaped like a streamlined tadpole with a long tail and an oval head. But most sperm are abnormal. Many sperm are born with two heads or two tails. Sometimes their heads range in size from puny to enormous. Sometimes their tails are crooked. Abnormal sperm is characterized by having abnormal head and tail structures. The head may be too large or too small. The tail can be crooked or even double. (Head Defects: small head; large head; double head; elongated head; vacuolated head; irregular head; amorphous head; small acrosome; no acrosome. Neck Defects: bent; thin; thick; irregular; cytoplasmic droplet. Tail Defects: coiled; short; hairpin; broken; duplicated; terminal droplet). These sperm abnormalities affect the sperm’s ability to swim and fertilize the egg. Those sperm shaped differently may have problems penetrating the surface of the woman’s egg. The shape (morphology) of a sperm is an important determinant of its fertilizability. The egg is enclosed in a protein coat called the zona pellucida (ZP). The ZP performs many functions, but its first task is to select which sperm will fertilize the egg. The ZP bases its selection on the shape of the sperm head. In order to pass through the ZP, the sperm must be vigorously motile and the sperm head must be a symmetrical, oval shape of the appropriate size. Sperm possessing heads that are irregular in shape, too round, too long, too big or too small are prevented from passing through the ZP. Additionally, abnormally shaped sperm often contain abnormal DNA. An abnormally shaped sperm may be short a chromosome or have an extra chromosome or the DNA is packed into the sperm head in such a way so that, if that abnormally shaped sperm were to enter the egg, the DNA would get all tangled up when it tries to form chromosomes inside the egg. Therefore, nature has evolved a way to keep abnormally shaped sperm from getting inside the egg and thereby maximizing the genetic development potential of the embryo.

Problems with semen

(4)           EPIDIDYMAL OBSTRUCTION

There is a crescent–shaped duct within the scrotum that collects sperm from the seminiferous tubules, called the epididymis. While sperm are passing through the epididymis, they mature and gain movement. In some men, the epididymis becomes blocked, preventing sperm from entering the vas deferens and getting into the ejaculate.

The epididymis is a twenty–foot–long, thin–walled, tightly coiled duct within the scrotum that collects sperm from the seminiferous tubules, where sperm are manufactured. It’s a crescent-shaped duct that runs longitudinally along the back of the testis and as its walls become thicker and straighter it becomes the vas deferens. While sperm are passing through the epididymis, they mature and gain movement. In some men, the epididymis becomes blocked, preventing sperm from entering the vas deferens and getting into the ejaculate. A blockage can occur on one side or on both sides. This blockage may be natural or may be caused by a hernia or hydrocele repair. If a man has an epididymal obstruction on one side, he may suffer a lowered sperm count. If a man has epididymal obstructions on both sides, this will lead to azoospermia (a zero sperm count).

This diagnosis must be confirmed by a testicular biopsy. A piece of the testis is taken either through an incision in the scrotum and testicle or with a needle. If good sperm production is found, then it is clear that production of sperm is not the issue, but the delivery of it into the ejaculate is. If other blockages are ruled out, a bypass of the blockage can be performed. This is called a vasoepididymostomy (because the vas deferens is reconnected to the epididymis.) As we’ve discussed in other sections, it’s important that a skilled specialist, experienced with this type of surgery, perform this operation.

If the obstruction cannot be repaired, there are still options available. Sperm may be retrieved from the scrotum. This can be done in a number of ways. It can be done with a needle into the testis, or an incision in the testis. Most commonly a Microscopic Epididymal Sperm Aspiration (MESA) is done to get sperm from the epididymis. There are two advantages to this procedure over retrieval of sperm from the testis. The first is that the sperm are more mature, and thus usually have better motility (movement). The second is that there are significantly more sperm in the epididymis than the testis. This is because the ducts within the testis have collected the sperm already and delivered them into the epididymis. Often, the sperm retrieved through MESA can be frozen and used in multiple IVF cycles.

Sperm retrieved from the testis or epididymis may be used to attempt conception for couples using in–vitro fertilization (IVF) combined with intracytoplasmic sperm insertion (ICSI). IVF means that the eggs are retrieved from the woman. ICSI means that the sperm are injected directly in an egg.

The most positive thing is that an epididymal obstruction does not mean untreatable infertility. There are a number of options available to male patients suffering from the blockage.

Male infertility is usually caused by problems that affect either sperm production or sperm transport.

(5)           SPERM PRODUCTION PROBLEMS: 

(5.1)       Undescended testes (failure of the testes to descend at birth);

(5.2)       Chromosomal or genetic causes;

(5.3)       Torsion (twisting of the testes in scrotum);

(5.4)       Varicocele (varicose veins in the testes);

(5.5)       Prostate–related problems;

(5.6)       Absence of vas deferens;

(5.7)       Vasectomy;

(5.8)       Infections;

(5.9)       Drugs;

(5.10)     Radiation damage.

(5.1)       Undescended testes (failure of the testes to descend at birth)

What are Undescended Testicles?

The testes develop inside the abdomen in the male fetus and then move down (descend) into the scrotum before or just after birth. Undescended testes (or cryptorchidism) is a condition when one (undescended testicle) or both of the testes have not descended into the scrotum at birth, but stay in the abdomen or only move part way down into the scrotum. The medical term for having one or two undescended testicles is unilateral or bilateral cryptorchidism. It’s estimated that about one in every 25 boys are born with undescended testicles, or, if you are interested in the average number, this issue is found in about 3 or 4 out of 100 newborns, but the majority of cases are in male babies born prematurely (up to 21 out of 100 premature newborns). In most cases, no treatment is necessary, as the testicles will usually move down into the scrotum naturally during the first three months of life: nearly half of these testicles will drop on their own. But testicles won’t drop on their own after 3 months of age. Thus, about 1 or 2 out of 100 babies with undescended testicles will need treatment. Undescended testicles are usually detected during the newborn physical examination carried out soon after birth, or during a routine check–up at six to eight weeks.

What causes Undescended Testicles?

During pregnancy, the testicles form inside a baby boy’s abdomen (tummy), before slowly moving down into the scrotum about a month or two before birth.

It’s not known exactly why some boys are born with undescended testicles. Most boys with the condition are otherwise completely healthy.

Being born prematurely (before the 37th week of pregnancy), having a low birth weight and having a family history of undescended testicles may increase the chances of a male baby being born with undescended testicles.

How are undescended testes linked with sperm production?

The testicles make and store sperm, and if they don’t descend they could become damaged. The testicles need to be 2 to 3 degrees cooler than normal body temperature to make sperm. The scrotum is many degrees cooler than body temperature, and so is the ideal place for the testicle. Testicles that don’t drop into the scrotum won’t work normally. It is believed that the warmer temperature in the abdomen damages the sperm–producing tubes in the testes. The longer the testes spend in the abdomen, the greater the effect on sperm production. The longer the testicles are too warm, the lower chances are that the sperm in that testicle will mature normally. This can be a cause of infertility, especially when both testicles are affected.

Undescended testicles are also linked to a higher risk of:

Testicular cancer in adulthood (though the risk is still less than 1 in 100);

Testicular torsion (twisting of the chord that brings blood to the scrotum);

Developing a hernia near the groin.

It’s important not to confuse undescended testicles with “retractile” testicles. After 6 months of age, a male baby has a reflex that temporarily pulls the testicles up to protect them when he’s cold or frightened. These testicles are in the scrotum at other times and don’t need treatment. Only testicles that are truly undescended need treatment. The difference can be transparently explained by the pediatric urologist during a physical exam.

(5.2)       Chromosomal causes or genetic causes

What chromosomal causes/genetic problems affect sperm production?

Changes to chromosomes and genes can cause abnormal sperm production or blockages to sperm flow. Chromosomes are the structures in cells that carry genetic information. Each cell in the body normally has 46 chromosomes. Translocation, a chromosomal abnormality that occurs when chromosomes break and connect with other chromosomes, is the most common genetic cause of infertility. Genetic abnormalities can be detected by a blood test called a karyotype. It’s important to remember that a successful prior pregnancy does not prove either parent is free of translocations that could affect a future pregnancy.

Microdeletions of the Y chromosome (MDY), also known as Deleted in Azoospermia (DAZ), abnormalities can lead to dramatic reductions in sperm production. The Y (male) chromosome carries certain genes which are essential for sperm production. If there are mutations in these genes sperm production can be absent or very low.

Another genetic abnormality is Klinefelter’s syndrome, in which the male carries an extra X chromosome. Klinefelter’s syndrome can sometimes cause an absence of sperm production and other reproductive problems in the male.

Men who have Noonan syndrome may also experience infertility. This rare syndrome is characterized by short stature, webbed neck, low set ears, and cardiovascular abnormalities.

(5.3)       Torsion (twisting of the testes in scrotum)

What is Testicular Torsion? How does torsion of the testis affect sperm production?

Men have two testicles that rest inside the scrotum. Each testicle is attached to the spermatic cord and the scrotum. A cord known as the spermatic cord carries blood to the testicles. Testicular torsion happens if the testicle rotates on the cord that runs upward from the testicle into the abdomen. When a man experiences torsion of testes, this cord twists. The rotation twists the spermatic cord and reduces blood flow. If the testicle rotates several times, blood flow is affected or can be entirely blocked, causing damage more quickly and, as a result, the tissues in the testicle can start to die. Testicular torsion is a true urologic surgery emergency, since it causes strangulation of gonadal blood supply with subsequent testicular necrosis and atrophy; a delay in diagnosis and management can lead to loss of the testicle.

Symptoms of testicular torsion: 

Sudden or severe pain in one testicle;

One testicle is positioned higher than normal or at an odd angle (The affected testicle may become larger, and it may become red or dark in color);

Swelling of the scrotum, the loose bag of skin that contains the testicles;

Lumps in the scrotum;

Nausea;

Blood in the semen;

Vomiting;

Abdominal pain.

Symptoms usually appear suddenly, although in some cases, the torsion can develop over a few days. It is important to seek emergency care for sudden or severe testicle pain. The signs and symptoms may be caused by another condition, but prompt treatment can prevent severe damage or loss of the testicle if it is testicular torsion.

If there is sudden testicle pain that goes away without treatment, it may be that a testicle has twisted and then untwisted without intervention. This is known as intermittent torsion and detorsion.

Even if the testicle untwists on its own, it is important to seek prompt medical help, because surgery may be needed to prevent the problem from happening again.

Testicular torsion in newborns and infants: sometimes, testicular torsion happens before birth. In this case, the testicle cannot normally be saved, but correctional surgery is recommended after birth to diagnose and correct testicular torsion in the other testicle and to prevent future reproductive problems.

Most common in teenagers and young men, torsion of the testis happens when the testis twists in the scrotum. The twisting of the testis cuts off the blood supply to the testis, causing damage to the tubes that produce sperm. If this problem only happens in a single testis, the other testis should continue to make sperm and natural conception can happen. This is a medical emergency; early diagnosis and treatment (immediate surgery) are vital to saving the testicle and preserving future fertility, as surgical treatment may prevent further ischemic damage to the testis (if treated within 4–6 hours, the testicle can usually be saved. The sooner the testicle is untwisted, the greater the chance of successful treatment. After 6 hours, lasting damage may occur, and after 12 hours, there is a 75 percent chance of losing the testicle.). The operation is simple and minimally invasive. It is normally conducted under general anesthesia, and it does not usually require a stay in the hospital. During the surgery, the other testis should also be fixed in position to stop it twisting, the surgeon will make a cut in the scrotum, if necessary –– untwist the spermatic cord, stitch one or both testicles to the inside of the scrotum, to prevent rotation. Suturing both testicles will prevent torsion from occurring on the other side.

(5.4)       Varicocele (varicose veins in the testes); 

What is a Varicocele?

The scrotum is a skin–covered sac that holds testicles. It also contains the arteries and veins that deliver blood to the reproductive glands. A vein abnormality in the scrotum may result in a varicocele. A varicocele is an enlargement of the veins within the scrotum. These veins are called the pampiniform plexus. A varicocele only occurs in the scrotum and is very similar to varicose veins. A varicocele can result in decreased sperm production and quality, which in some cases can lead to infertility. It can also shrink the testicles. The anatomy of the right and left side of scrotum isn’t the same. Varicoceles can exist on both sides, but it’s extremely rare. Not all varicoceles affect sperm production.

What causes a varicocele to develop?

A spermatic cord holds up each testicle. The cords also contain the veins, arteries, and nerves that support these glands. In healthy veins inside the scrotum, one-way valves move the blood from the testicles to the scrotum, and then they send it back to the heart. Sometimes the blood doesn’t move through the veins like it should and begins to pool in the vein, causing it to enlarge.

There are no established risk factors for developing a varicocele, and the exact cause is unclear.

Symptoms of a Varicocele:

a lump in one of the testicles;

swelling in the scrotum;

visibly enlarged or twisted veins in the scrotum, which are often described as looking like a bag of worms;

a dull, recurring pain in your scrotum.

How does a varicocele affect sperm production?

A varicocele is a swelling of the veins (varicose veins) above the testis. When the blood doesn’t drain properly, the veins dilate (or enlarge). This extra blood that pools in the scrotum, raises the temperature and negatively impacts sperm production. Men with varicoceles often have a lower than average number of sperm, poorer sperm movement and an increase in the number of abnormally shaped sperm. There is some research showing that the temperature of the testis with a varicocele is higher. A higher temperature could damage healthy sperm production.

Methods of treatment for Varicoceles

Varicocelectomy

A varicocelectomy is a same–day surgery that’s done in a hospital. A urologist will go in through your abdomen and clamp the abnormal veins. Blood can then flow around the abnormal veins to the normal ones. Talk with your doctor about how to prepare for the surgery and what to expect after the operation.

Varicocele Embolization

Varicocele embolization is a less invasive, same–day procedure. A small catheter is inserted into a groin or neck vein. A coil is then placed into the catheter and into the varicocele. This blocks blood from getting to the abnormal veins.

(5.5)       Prostate–related problems

The prostate gland is the walnut–sized gland that makes up part of a man’s reproductive system. It secretes a fluid that contributes to the semen that sperm swim in. The term prostatitis refers to inflammation of the prostate gland. Acute bacterial prostatitis is simple. It is an infection of the prostate that responds to antibiotics. Unfortunately, chronic prostatitis is not so simple — and it’s a lot more common than acute prostatitis. It’s also more difficult to understand. Doctors tend to have trouble both diagnosing it correctly and treating it successfully. To add to the complexity, several studies have found a link between chronic prostatitis and fertility problems in men.

(5.6)       Absence of vas deferens

What is congenital bilateral absence of Vas Deferens? 

The vas deferens is a long, tube–like structure that connects the epididymis (the site of sperm storage) to the urethra (the tube that expels sperm). During ejaculation, the sperm flows out of the testicles, through the vas deferens and into the urethra, which leads outside the body through the penis.

Congenital Bilateral Absence of Vas Deferens (CBAVD) is a condition where a male baby is born without the vas deferens. The vas deferens are tubes that transport sperms out of the testes. This greatly affects a man’s fertility since the sperm are essentially stuck in the testicles, with no way of reaching the urethra and exiting out of the body.

A complete lack of sperm in the man’s semen –– a condition known as azoospermia –– can be a symptom of this condition. The inability to conceive is another indication that a man may have a fertility issue such as bilateral absence of the vas deferens.

What causes an absence of vas deferens to develop?

This condition is congenital, meaning that it exists at birth. The presence of congenital bilateral absence of vas deferens is strongly associated with cystic fibrosis. In fact, azoospermia and infertility are found in 95% of the males who survive to adulthood and congenital bilateral absence of vas deferens is common among these patients. In some cases, congenital bilateral absence of vas deferens may be the only feature suggesting an underlying mutation on the gene that causes cystic fibrosis. It is imperative that both partners are screened for cystic fibrosis, including a test for what is called the 5T polyvariant to be sure that they are not passing on cystic fibrosis to their offspring. Genetic counseling can help interpret the results. If both are found to be carriers, preimplantation genetic diagnosis (PGD) is an option.

Congenital Bilateral Absence of Vas Deferens is caused by mutations in the CFTR gene, which through a complex process, obstructs the development of the vas deferens, leading to their disintegration. In cases that are not associated with cystic fibrosis, the exact cause of Congenital Bilateral Absence of Vas Deferens is unknown. Congenital Bilateral Absence of Vas Deferens cannot be cured, since the vas deferens cannot be restored. Nonetheless, successful pregnancies are possible due to procedures that enable sperm retrieval for medically–assisted reproduction.

(5.7)       Vasectomy 

What is Vasectomy? 

A vasectomy is a surgical procedure performed as a permanent method of birth control. However, there is a very small possibility of failure, less than 1%, with either method. It is a simple surgical procedure that seals the sperm–carrying tubes (the vas deferens) to prevent sperm from entering the fluid you ejaculate. With regard to vasectomy this can be categorized as short–term or long–term failure. The vasectomy procedure involves sealing the sperm–carrying tubes but, in rare cases, the tubes may join together naturally.

(5.8)       Infections 

What infections can affect sperm production?

Orchitis (infection in the testes) can damage the sperm–producing tubes (seminiferous tubules) and stop sperm production. Even though the infection is often only temporary, severe damage can leave men permanently infertile. Mumps is the most common infection of the testes (mumps orchitis) but is now less common due to immunization programs.

(5.9)       Drugs

How do other medicines affect sperm production? [Effects of Pharmaceutical Medications on Male Fertility]

There are a number of commonly used medicines that may have a negative effect on sperm production and function.

Cyclophosphamide, a medicine used for the treatment of some cancers and kidney disorders, can cause permanent infertility if the treatment is given for a long time. Testosterone (tablets or injections), which are used to treat men with testosterone (androgen) deficiency, can cause fertility problems. Testosterone treatment stops the production of the pituitary hormones (FSH and LH), which normally act on the testes to make sperm. Testosterone reduces the size of the testes and can lower or stop sperm production. Even common medications may have a negative effect on sperm production and/or function. Some of those include: Ketoconazole (an anti–fungal); Sulfasalazine (for inflammatory bowel disease); Spironolactone (an anti–hypertensive); Calcium Channel Blockers (anti–hypertensives); Allopurinol, Colchicine (for gout); Antibiotics: Nitrofuran, Erythromycin, Gentamicin; Methotrexate (cancer, psoriasis, arthritis); Cimetidine (for ulcer or reflux). The following drugs can cause ejaculatory dysfunction: Antipsychotics: Chlorpromazine, Haloperidol, Thioridazine; Antidepressants: Amitripltyline, Imipramine, Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft); Anti–hypertensives: Guanethidine, Prazosin, Phenoxibenzamine, Phentolamine, Reserpine, Thazides.

(5.10)     Radiation damage

Can testicular cancer affect sperm production?

Cancer in a single testis may not affect the chance of having children. After a cancerous testis is removed, in many men the remaining testis continues to make testosterone and sperm. However, some men who have had testicular cancer may have trouble having children. Men who are diagnosed with testicular cancer are more likely to have lower fertility before any treatment starts. Fertility can be further affected by cancer treatments such as radiotherapy and chemotherapy.

How does radiotherapy affect sperm production?

Radiation treatment or ‘radiotherapy’ uses high energy X–rays to kill cancer cells in a specific area while limiting damage to normal cells. Radiotherapy for testicular or other cancers near the testes can damage the testis, leaving permanent problems with sperm production. During radiotherapy, the other non–affected testis is shielded from the X–rays but some exposure may happen. The effects of radiotherapy can be temporary or permanent. As radiation can cause genetic damage in the early development stages of sperm (germ cells), it is highly recommended by the experts to avoid attempting a pregnancy for six to 12 months (depending on the type of treatment) after radiotherapy.

How does chemotherapy affect sperm production?

Chemotherapy medicines act to stop or slow the growth of cancer cells. Chemotherapy also attacks normal cells, such as the cells in the lining of the sperm–producing tubes in the testis. Chemotherapy can temporarily or permanently destroy developing sperm cells. Most men will return to the level of fertility they had before chemotherapy, but this can take up to five years. In some cases, fertility is permanently reduced.

(6.)          SPERM TRANSPORT PROBLEMS

Sperm transport problems: obstructions (often referred to as blockages) in the tubes leading sperm away from the testes to the penis can cause a complete lack of sperm in the ejaculated semen.

BLOCKAGE OF SPERM TRANSPORT: 

(6.1)       Infections;

(6.2)       Prostate related problems;

(6.3)       Absence of vas deferens;

(6.4)       Vasectomy.

(6.1)       Infections 

What infections can affect sperm transport?

Men may have infections of their reproductive tract. These may include infections of the prostate (prostatitis), of the epididymis (epididymitis), or of the testes (orchitis). Bacterial infections or sexually transmitted diseases can cause blockages of the sperm ducts. In these cases, sperm production may be normal but the ducts carrying them are blocked. Active bacterial or viral infections may also have a negative effect on sperm production or function. White blood cells, the body’s response to infection, can also have a negative effect on sperm membranes, making them less hearty. When excessive white blood cells (more than one million/cc) are found in a semen specimen, we recommend having cultures performed on the specimen. These cultures include tests for commonly asymptomatic, sexually–transmitted diseases: mycoplasma, ureaplasma, and Chlamydia. Also, a general genital culture is usually taken. If the infection and the white blood cells are persistent, antibiotics may be considered.

(6.2)       Prostate related problems

What is the prostate gland? 

The prostate is a small but important gland in the male reproductive system. It is usually the size and shape of a walnut and grows bigger as you get older. It sits underneath the bladder and surrounds the urethra, which is the tube men urinate and ejaculate through. The prostate is made up of a number of small glands surrounded by supporting tissue called the stroma (the tissue or supporting framework of an organ). The small glands in the prostate make the fluid. The prostate is surrounded by pelvic floor muscles, which contract during ejaculation to help move the fluid into the urethra.

What is its role in reproduction?

The main role of the prostate gland is to make fluid that protects and feeds sperm. The prostate gland makes fluid that forms a major part of semen (mixture of sperm and fluid). The fluid from the prostate helps the sperm flow along the ducts (tubes) of the male reproductive system. Sperm are made in the testes and then pass along the highly coiled epididymis, through the vas deferens to the prostate. The prostate gland and other glands (the seminal vesicles and Cowper’s gland) make the fluid that mixes with the sperm. Semen then travels along the urethra to the tip of the penis where it is ejaculated (released) at orgasm. To stop semen flowing backwards into the bladder during ejaculation, an internal sphincter (muscle) at the base of the bladder and the top of the prostate closes. An external sphincter (a pelvic floor muscle) at the end of the prostate relaxes to release the fluid from the prostate into the urethra.

What is prostate gland’s disease? 

Prostate disease describes any medical problem that affects the prostate gland. Common prostate problems include:

(1) Benign prostatic hyperplasia or hypertrophy (BPH): a benign (non–cancerous) enlargement of the prostate gland;

(2) Prostatitis: inflammation of the prostate gland, sometimes because of infection

(3) Prostate cancer: a problem where cells within the prostate grow and divide abnormally so that a tumour forms.

Only prostate cancer and the uncommon condition acute bacterial prostatitis can be life–threatening. Although, both inflammation and enlargement of the prostate can be very painful and have a major effect on quality of life.

(6.3)       What genetic problems can affect sperm transport?

Congenital absence of the vas deferens is a rare genetic problem that causes infertility in about 1 in 2500 men. Many men with congenital absence of the vas deferens have a mutation (genetic change) in the cystic fibrosis (CF) gene. Several parts of the reproductive tract (including the vas deferens) are missing from birth (congenital). This stops sperm moving from the testes into the ejaculate.

(6.4)       Can a vasectomy be a fertility problem?

Vasectomy is a surgical operation that cuts the tubes that carry the sperm from the testes (the vas deferens or the ‘vas’). The goal of a vasectomy is to make a man sterile, that is, unable to father children naturally. It is a very effective, safe and permanent form of contraception.

Why is it important to think about sperm storage before vasectomy?

Even though only a small fraction of men who undergo vasectomy want another baby, some men store sperm before a vasectomy ‘just in case’. This may prevent the need for a vasectomy reversal in the future; however, when using stored sperm, the female partner will still need some form of assisted reproductive technology (ART) to fall pregnant.

(7)           SEXUAL PROBLEMS (ERECTION AND EJACULATORY PROBLEMS): 

(7.1)       Premature ejaculation;

(7.2)       Delayed ejaculation or Failure of ejaculation;

(7.3)       Erectile dysfunction

Problems with erections (erectile dysfunction) or ejaculation. Problems with ejaculation that can cause infertility include: (1) retrograde ejaculation, a problem where semen flows back into the bladder; (2) premature ejaculation, where ejaculation occurs sooner than desired; (3) anorgasmia, where ejaculation does not happen at all.

(7.1)       Premature ejaculation

What is premature ejaculation? What are its causes, incidence, and risk factors?

Premature ejaculation is considered the most common sexual dysfunction in men. Premature ejaculation used to be attributed completely to psychological causes. The most important thing to keep in mind is this: even if premature ejaculation cannot be cured, it can be managed successfully. It is hard to define premature ejaculation by standard medical metrics. Premature ejaculation refers to the entry of semen into the bladder instead of going out through the urethra during ejaculation. The condition may cause infertility. Retrograde ejaculation may be caused by prior prostate or urethral surgery, diabetes, some medications, including some drugs used to treat hypertension (high blood pressure) and some mood–altering drugs. If retrograde ejaculation is caused by drugs, removal of the specific drug may resolve the condition. Retrograde ejaculation caused by diabetes or following genitourinary tract surgery may be responsive to the use of epinephrine–like drugs (such as pseudoephedrine or imipramine).

(7.2)       Delayed ejaculation or failure of ejaculation

What is delayed ejaculation? 

Delayed ejaculation may be categorized as lifelong (occurring since sexual maturity) or acquired (occurring after a period of normal sexual functioning). It is further categorized as generalized or situational. This is important to identify as it will help in determining which treatment options are most effective.

Causes of delayed ejaculation

Delayed ejaculation can be caused by chronic medical problems, certain medications or surgery. It may also have psychological causes. In some instances, it is a combination of both physical and psychological causes.

Physical Causes

Physical causes include nervous system disease (i.e. stroke), injury to the back or spine, endocrine disease (i.e. diabetes), prostate disease or surgery and heart surgery. Certain types of medication may also cause delayed ejaculation. These medications can include antidepressants, antipsychotics and antihypertensives. Delayed ejaculation may also occur with excessive alcohol use or recreational drug use.

Psychological Causes

Psychological causes of delayed ejaculation include relationship problems, anxiety, depression and other mental health problems, fatigue, performance anxiety, conditioning caused by a history of unusual masturbating and cultural or religious issues.

(7.3)       Erectile dysfunction

What is erectile dysfunction? 

Erectile dysfunction is clearly an age–related phenomenon since the prevalence of ED increases significantly with age. In the majority of cases involving men older than 35, the causes are primarily physical. In men younger than 35, the causes tend to be primarily psychological. By age 40, approximately 40% of men experience mild to moderate erectile dysfunction. Roughly 5% are never able to achieve an erection rigid enough for penetration.

Causes of Erectile Dysfunction

There are four main causes of erectile dysfunction:

Vascular

Blood must be able to move into the penis and stay there to maintain an erection. Arteries are the vehicles that bring blood into the penis. Any process that damages the arteries would make a man more likely to have erectile dysfunction. A history of arterial disease (e.g. heart attacks, strokes or peripheral vascular disease) indicates that the penile arteries are also at risk. Anything that would make a man more likely to have a heart attack or stroke will make him more likely to have erectile dysfunction. This includes smoking, diabetes, hypertension, high cholesterol and sub-optimal exercise and diet. In fact, erectile dysfunction usually appears before any of these more severe manifestations of vessel disease. One of the main reasons for this is that the artery to the penis is smaller than the heart or limb arteries, and gets clogged first. The development of erectile dysfunction is often the first sign that a man is at significantly increased risk of a heart attack or stroke.

Neurological

The neurological system must be in tact in order to achieve an erection. The most common cause of neurologic erectile dysfunction is diabetes, which usually affects both nerves and blood flow. Other causes include previous surgeries, spinal cord injury, strokes, multiple sclerosis or other systemic neurological diseases.

Hormonal

Significantly low testosterone and thyroid hormones, or a very high prolactin (another pituitary hormone) may cause problems with erections.

Psychological

Erectile dysfunction can often occur for psychological reasons, even when any related physical problems are minimal. However, many men have a significant psychological response (or secondary reaction) to what is, at least at first, primarily a physical problem. Once a man loses confidence in his erections, his anxiety levels may increase. This can make it even harder to achieve and maintain an erection. Thus, a vicious cycle is created. Our job is to break this cycle.

Erectile dysfunction treatments: Oral Treatment Options for Erectile Dysfunction / Male Impotence; Penile Injection Treatment for Erectile Dysfunction; Vacuum Erection Device (VED); MUSE; Penile Prosthesis (Penile Implant); Herbal Alternatives for Treating Erectile Dysfunction.

(8)           HORMONAL PROBLEMS:

(8.1)       Congenital lack of LH/FSH (pituitary problems from birth);

(8.2)       Pituitary tumors;

(8.3)       Anabolic (androgenic) steroid abuse.

The testicles need pituitary hormones to stimulate them to make sperm. If these hormones are absent or severely decreased, the testes cannot produce sperm to maximum capacity. It is important to note that men who take androgens (steroids) for body building, either by mouth or injection, shut down the production of hormones for sperm production. In about one in 100 infertile men the problem is caused by low levels of hormones made in the pituitary gland that act on the testes. Low production of follicle stimulating hormone (FSH) and luteinising hormone (LH) can affect testosterone levels in the testes, and lower sperm production. The most common hormonal problems are pituitary tumors or problems with the development of the pituitary gland leading to a lack of follicle stimulating hormone (FSH) and luteinising hormone (LH).

(9)           ANTISPERM ANTIBODIES:

(9.1)       Injury or infection in the epididymis;

(9.2)       Vasectomy;

(9.3)       Unknown cause.

What are antisperm antibodies? How do they form?

Sperm antibodies are formed in response to antigens. These antigens are proteins, which appear on the outer sperm membranes as the young sperm cells develop within the male testes. In the man’s own body, his sperm are regarded as foreign invading proteins and as such would normally be targeted for attack. However, under normal conditions, direct contact between the man’s blood and sperm is prevented by a cellular structure in the testes called the blood/testis barrier. This barrier is formed by so–called, Sertoli cells, which abut very closely against each other, forming tight junctions that separate the developing sperm cells from the blood and prevent immunologic stimulation.

Any disturbance to this system [the blood/ testis barrier] infection, chemical, physical, inflammation and trauma could break the barrier and sensitize the immune system to sperm. When this barrier is breached, sperm antigens escape from their immunologically protected environment and come in direct contact with blood elements that launch an immunologic attack.

Once sperm and blood come in contact, specific antibodies are produced against them by specialized blood cells call T– and B–lymphocytes. The three main types of sperm antibodies produced are Immunoglobulin G (IgG), Immunoglobulin A (IgA) and Immunoglobulin M (IgM). These antibodies bind to the proteins (antigens) on the sperm’s head, midpiece or tail. The antibodies formed may be of the circulatory type (in the blood serum) or secretory type (in the tissue). This is important because high levels of antibodies in the blood serum do not invariably mean that the antibodies will find their way to the semen where they can affect the sperm. For example, the concentration of IgG is much lower in secretions of the reproductive tract than it is in the blood. Conversely, the local level of IgA is higher in the reproductive secretions than in the blood.

Once sperm antibodies have formed, they can affect sperm in several different ways. Some antibodies will cause sperm to stick together or agglutinate. Agglutinated sperm clump together in dense masses and thus are unable to migrate through the cervix into the uterus. Other antibodies mark the sperm for attack by Natural killer (NK) cells of the body’s immune system (i.e. opsonizing antibodies).

Some antibodies cause reactions between the sperm membrane and the cervical mucus preventing the sperm from swimming through the cervix (i.e., immobilizing antibodies). Antibodies can also block the sperm’s ability to bind to the zona pellucida of the egg, a prerequisite for fertilization (i.e., blocking antibodies).

Finally, there is recent evidence that the fertilized egg shares some of the same antigens that are found on the sperm. It is possible that sperm antibodies present in the mother can react with the early embryo, resulting in its destruction by phagocytic cells (i.e.; phagocytic antibodies).

There are a number of diagnostic tests available to detect the presence of sperm antibodies. These are performed by flow cytometry and the ELISA (enzyme–linked immunoabsorbent assay), the Franklin-Dukes sperm agglutination assay or the Immunobead Binding Test (IBT), to name a few. At SIRM, the indirect Immunobead Binding Test (IBT) is used to detect antibodies present in the blood serum, in cervical mucus or on the sperm surface.

In the male, IgA and IgG are found in the semen although there is controversy as to whether they originate locally (secreted by testicular cells) or cross over from the circulation. Antibodies of the IgM class are not found in semen.

The origins of antisperm antibodies are uncertain –– it is not whether they are produced by the body or the testis.

Why does antisperm antibodies interfere with fertilization?

It is well known that naturally occurring antibodies to eggs and sperm can cause problems with fertility. The antibodies bind to the proteins (antigens) on the sperm’s head, midpiece or tail.

Antisperm antibodies could cause sperm inaction in 3 ways:

(1)           agglutination (clumping and sticking together) reducing the number of sperm penetrating cervical mucus;

(2)           immobilization of sperm –– sperm is unable to move;

(3)           spermatotoxic –– causing loss in viability of the sperm.

Medical tests have already revealed valuable information that in some men antibodies may be found in the blood and these are known as circulatory antibodies. High levels of antibodies in the blood do not invariably mean that the antibodies will find their way to the semen where they can affect the sperm. Antibodies may also interfere with egg penetration and sometimes prevent the sperm from swimming through the cervix.

About four in five men develop sperm antibodies after having a vasectomy. It is possible for a man to develop antibodies to his own sperm. This can occur because of testicular trauma, testicular infection, large varicoceles, or testicular surgery. Sometimes, there are unexplained reasons for this occurrence. The antibodies have a negative effect on fertility, but the reason isn’t clear. Most likely, the antibodies cause the sperm to have trouble penetrating the partner’s cervical mucous and making their way to the uterus. It may become more difficult for the sperm to bind with the external membrane, shell, of the egg, or to fuse with the eggs themselves.

MALE INFERTILITY TESTING 

The most important first step in any man’s evaluation is the semen analysis. The semen analysis allows us to identify problems to be addressed in order to maximize the quality of the man’s semen. This may reduce the need for more complicated interventions for the female partner. It will also allow us to rule out significant medical problems that may contribute to poor analysis results.

Semen Analysis

Semen is the fluid that a man ejaculates. It is produced at several different sites in the body. The sperm within the semen are the cells that actually fertilize the egg. While it is most important to assess the sperm, they account for only 1% to 2% of the semen volume. Problems with the surrounding fluid may also interfere with the movement and function of the sperm. Therefore, both the sperm and the fluid must be tested. Semen analysis is the laboratory testing of freshly ejaculated semen that usually has been produced by masturbation. Under a microscope, the number, shape and movement of sperm are measured. A semen analysis is a vital part of diagnosing male infertility. Testing should be done at a specialized laboratory that uses methods approved by the World Health Organization (WHO); special equipment and expertise are needed to do an accurate semen analysis. There is no specific, magic number of sperm in the semen analysis of men whose partners will get pregnant. The partners of some men with a very poor semen analysis may conceive easily. The partners of some men with an excellent semen analysis may experience difficulty. However, men with good semen analysis results will, as a group, conceive at significantly higher rates than those with poor semen analysis results. The semen analysis will help determine whether there is a male factor involved in the couple’s sub-fertility. In those cases, we will recommend an evaluation. There are certain findings of the semen analysis which suggest specific potential problems. For example, an increased white blood cell count may indicate infection or inflammation. However, other abnormalities in many of the main parameters are non-specific. For example, there are a number of different causes for a decreased sperm count or diminished sperm movement. Some of these causes have other serious medical implications, others don’t. A thorough evaluation helps determine the cause of an abnormal semen analysis.

Standard Semen Analysis Tests

Almost all laboratories will conduct tests and report on the following information, using values established by the World Health Organization:

Concentration (sometimes referred to as “the count”): This is a measurement of how many million sperm there are in each milliliter of fluid. There are various techniques for obtaining this number. Some prove to be more accurate than others. Average sperm concentration is more than 60 million per milliliter (>60 million/cc). Counts of less than 20 million per milliliter (<20 million/cc) are considered sub–fertile.

Motility (sometimes referred to as “mobility”): This describes the percentage of sperm that are moving. Fifty percent or more of the sperm should be moving.

Morphology: This describes the shape of the sperm. The sperm are examined under a microscope and must meet specific sets of criteria for several sperm characteristics in order to be considered normal. Most commercial laboratories will report WHO morphology (use World Health Organization criterion). Thirty percent of the sperm should be normal by these criteria.

Volume: This is a measurement of the volume of the ejaculate. Normal is two milliliters (two ccs) or greater. The volume may be low if a man is anxious when producing a specimen, if the entire specimen is not caught in the collection container, or if there are hormonal abnormalities or ductal blockages.

Total Motile Count: This is the number of moving sperm in the entire ejaculate. It is calculated by multiplying the volume (cc) by the concentration (million sperm/cc) by the motility (percent moving). There should be more than 40 million motile sperm in the ejaculate.

Standard Semen Fluid Tests: Color, viscosity (how thick the semen is), and the time until the specimen liquefies should also be measured. Abnormalities in the seminal fluid may adversely affect the sperm. For example, if the semen is very thick, it may be difficult for the sperm to move through it and into the woman’s reproductive tract.

Additional Semen Analysis Tests

Anti–Sperm Antibodies: Some men may produce antibodies to their own sperm. These antibodies may decrease fertility rates in a number of ways. They may impede the movement of sperm through a woman’s cervical mucous, inhibit the binding of a sperm to the egg, and/or inhibit its penetration into the egg. Men who are most at risk for developing antibodies are those with previous testicular and epididymal infection, trauma, surgery, or large varicoceles. The presence of these antibodies is often not predictable from other semen parameters or from the man’s history.

Forward Progression: This describes how well the sperm that are moving are making progress. Only when the motility (percent moving) is combined with the forward progression is an accurate picture of sperm movement obtained. Unfortunately, this is often not tested by commercial laboratories. A man’s motility may be normal and the fact that the sperm are moving sluggishly or almost not at all will be overlooked if the forward progression is not recorded separately.

Kruger Morphology: This is a more detailed evaluation of the morphology. Slides are specially stained and the sperm examined microscopically under high-power magnification. The sperm must meet a stringent set of criteria that evaluate the shape and size of the head, midpiece, and tail in order to be considered normal. A Kruger test helps determine which of the available advanced reproductive techniques may be most appropriate and successful.

White Blood Cells: The semen may contain a high number of white blood cells, which may be an indication of either infection or inflammation. White blood cells are considered significant if more than one million are found in each milliliter of the ejaculate. White blood cells cannot be differentiated from other round cells normally found in the semen (debris and immature sperm) without special staining. If more than one-million round cells are found in the ejaculate, a portion of the ejaculate should be specially stained to look for an increased number of white blood cells.

If the white blood cell count is elevated, semen cultures should be performed on a subsequent specimen. Unfortunately, the semen culture cannot be performed on the original specimen as it must be the first step performed on the specimen in order to keep it sterile.

Other Tests

In certain situations, specialized tests are needed. These depend on the findings at the time of the analysis and can often be performed on that specimen.

Spun Specimen: Even if no sperm are seen on the test slide, the sperm count may still not be zero (there may be very low numbers of sperm in the ejaculate). This has very important implications as it may determine if the couple can conceive using advanced reproductive techniques. This must be assessed by spinning down the specimen so all of the sperm are concentrated in a pellet on the bottom of the tube and then examining the pellet beneath the microscope.

Viability: Sperm may be alive, but not moving. A specialized staining technique is used to determine what percentage of the sperm are alive and is indicated when the motility (percent moving) is less than thirty percent.

Fructose: In men with no sperm or very low numbers of sperm in the ejaculate, it is important to determine whether the sperm are not being produced at all, or whether they are being produced but are blocked from “getting into” the semen. A fructose test can help differentiate between these two problems.

Post–Ejaculatory Urinalysis (PEU): Some men ejaculate all or part of the sperm backward into the bladder. This can be detected by having a man ejaculate and immediately afterward urinate into a separate cup. The post-ejaculatory urine is then centrifuged to see if any sperm are present.

Laboratory Needs

Expertise: Semen testing is a sophisticated and technical field. An improperly performed or incomplete semen analysis may miss significant problems. Unrecognized problems may unnecessarily delay a man’s treatment. Unlike many other lab tests which are mechanized, a semen analysis relies completely on the expertise of those performing it. Be sure the lab has sophisticated protocols and well–trained, specialized technicians.

Timing: In order to get accurate results, the specimen must be processed within one hour of collection. If not, the measurement of the movement of the sperm may be extremely inaccurate. With any lab men use, make sure that the analysis is performed on site and not shipped elsewhere for evaluation.

Thoroughness: As a semen analysis is being performed, certain findings may indicate the need for additional tests. Ideally, the male patients should use a laboratory that has the capability to do complete initial testing as well as the flexibility to do the appropriate follow–up testing on the same specimen.

CONCLUSION

MALE INFERTILITY TREATMENT

The purpose for all of this testing is to arrive at a treatment plan that can improve fertility. More than 50% of men will have a treatable cause of male factor infertility. These factors include varicoceles (dilated veins in the scrotum), infections, hormonal abnormalities, abnormalities in the seminal fluid, ductal blockages, and difficulties with erections and ejaculation. When these conditions are treated, either through medication (hormones or antibiotics) or surgery (varicocelectomy, vasal reconstruction, repair of a blocked ejaculatory duct), a man will often see a significant improvement in his semen analysis. Those men with poor semen analyses whose conditions are not treatable may still have the option of using advanced reproductive techniques to achieve a pregnancy. Even men with no sperm in the ejaculate may be able to have living sperm retrieved through other methods and achieve a pregnancy using advanced reproductive techniques. Those few men who produce absolutely no sperm at all will have this information so that they can explore other options.

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